Fillable PR OOF OF NURSE AIDE REGISTRATION PART I: (Arizona State Board of Nursing)

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PR OOF OF NURSE AIDE REGISTRATION PART I: (Arizona State Board of Nursing)

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PR
OOF OF NURSE AIDE REGISTRATION
Send this completed form to
the STATE AGENCY where you were originally a certified/registered.
(Addresses and phone numbers listed next page)
PART I: To be completed by the nursing assistant. PRINT CLEARLY.
NAME: Last First Middle Maiden Name or Other Names Used
Address: Number & Street City State Zip
Social Security Number: Date of Birth (Area Code) Telephone No.
State Of Current Certification: Certification Number: Date of Issue:
NURSE AIDE TRAINING PROGRAM: Provide Name of School or Program, City & State Date Completed
PART II: To be completed by the STATE AGENCY where you were originally certified/registered.
* If you are certified in Alabama, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii,
Illinois, Michigan, Mississippi, Missouri, Nebraska, New Mexico, New York, Ohio, Pennsylvania, North Carolina, and
Wisconsin verifications, fill in Part I only and return this form with your application to Arizona State Board of Nursing.
1. This individual is listed on the Nurse Aide Register and has met all relevant federal requirements under OBRA ’87 and ’89:
Yes Certification/Registration #: ____________________________ Expires:
No
Date of Issue:
2. Method of Registration (Check All That Apply)
Deemed to the Registry without competency evaluation
Registered by Endorsement from the State of ____________________________
Completed a State-Approved, training program of hours
Passed a State-Administered competency evaluation
Not Available
3. Is there documentation of substantiated abuse, neglect or misappropriation of resident property by this individual?
Yes, please explain
No
4. Is there documentation of a felony conviction in a court of law?
Yes, please explain
No
Not Available
It is hereby certified that the above facts are stated from official records pertaining to this individual in the office of the
undersigned.
Date Nurse Aide Registry Representative Title
Agency Telephone #
City State Zip
ARIZONA STATE BOARD OF NURSING ♦ NURSING ASSISTANT REGISTRATION PROGRAM
1740 W Adams ST., SUITE 2000 ♦ PHOENIX, AZ ♦ 85007 ♦ (602) 771-7800
Website: www.azbn.gov
SEAL
For applicants who are
certified in another state.
CONTACT APPROPRIATE REGISTRY FOR CURRENT STATUS & FEES REQUIRED ON VERIFICATION
ALABAMA
AL CNA Registry, AL Dept of
Public Health
Div of Health Care Facilities
PO Box 303017
Montgomery, AL 36130-3017
334-206-5169
ALASKA
NA Registry
Dept of Commerce, Community, &
Econ Development
Div of Corp, Bus, & Prof Licensing
550 W 7
th
Ave, #1500
Anchorage, AK 99501
907-269-8169
ARIZONA
AZ State Board of Nursing
1740 W Adams Street, Suite 2000
Phoenix, AZ 85007
602-771-7800
ARKANSAS
Office of Long Term Care
501-682-1807
www.arkansas.gov/dhs/sgNH.html
*CALIFORNIA
Dept of Health Svcs
CNA/HHA/CHT Cert Unit
Lic & Cert Program
ATCS-MS 3301
PO Box 997416
1615 Capitol Ave
Sacramento, CA 95899-7416
916-327-2445
*COLORADO
CO Board of Nursing
1560 Broadway, #1370
Denver, CO 80202
303-894-2430
CONNECTICUT
Prometric CT Nurse Aide Prog
E-mail: ctcna@prometric.com
866-499-7485
DELAWARE
Div of Long Term Care Residents
Protection
3 Mill Rd, #308
Wilmington, DE 19806
302-577-6666
*DIST. OF COLUMBIA
Pearson VUE
888.274.6060
BON
202.724.8846
FLORIDA
Dept of Health
CNA Registry
4052 Bald Cypress Way
BIN#C-13
Tallahassee, FL 32399-3263
850-245-4125 X3784
GEORGIA
GA Medical Care Foundation
GA Nurse Aide Registry
PO Box 105753
Atlanta, GA 30348
www.mmis.georgia.gov
HAWAII
Prof & Voc Lic Branch
Dept of Commerce & Consumer
Affairs
PO Box 3469
Honolulu, HI 96801
808-734-2101 X122
IDAHO
ID Nurse Aide Prog
PO Box 83720
Boise, ID 83720-0036
800-748-2480
*ILLINOIS
IL Dept of Public Health
Health Care Wkr Registry
525 W Jefferson St, 4
th
Flr
Springfield, IL 62761
217.785.5133
INDIANA
IN Dept of Hlth, Div of LTC
2 N Meridian St, Sec 4B
Indianapolis, IN 46204
317-233-7351
IOWA
Direct Care Wkr Registry
Div of Health Facilities
IA Dept of Insp & Appeals
Lucas State Office Bldg
Des Moines, IA 50319-0083
515-281-4077
KANSAS
KS Dept of Health & Envirmnt
Health Occup Credentialing
1000 SW Jackson, #200
Topeka, KS 66612-1365
785-296-6877
KENTUCKY
KY Board of Nursing
312 Whittington Pkwy, 300-A
Louisville, KY 40222
888-530-1919
LOUISIANA
LA State Bd of Exam for Nsg
Facility Admin, NFA
Nurse Aide Registry
5647 Superior Dr
Baton Rouge, LA 70816
225-295-8575
MAINE
ME Registry of CNAs
ME HHS
State House Station 11
41 Anthony Ave
Augusta, ME 04333
207-624-7300
MARYLAND
MD Board of Nursing
4140 Patterson Ave
Baltimore, MD 21215-2254
410.585.1918
MASSACHUSETTS
MA Nurse Aide Registry
MA Dept of Public Health
Div of Hlth Care Quality
99 Chauncy St, 2
nd
Fl
Boston, MA 02111
617-753-8143
*MICHIGAN
MI Dept of Community Health
Bureau of Hlth Professions
PO Box 30670
Lansing, MI 48909
517-241-0554
MINNESOTA
Div of Compliance Monitoring
NA Registry
PO Box 64501
St. Paul, MN 55164-0501
651-215-8705
*MISSISSIPPI
MS Dept of Health Bureau of
Health Facilities – Lic & Cert
143-B LeFleur’s Sqr
PO Box 1700
Jackson, MS 39215-1700
614-364-1100
MISSOURI
MO Dept of Health & Senior Svcs,
Health Educ Unit
PO Box 570
3418 Knipp
Jefferson City, MO 65102
573-526-5686
MONTANA
MT Dept of Pub Hlth & Human
Svcs – Cert Bureau
2401 Colonial Dr, 2
nd
Fl
Helena, MT 59620-2953
406.444.4980
*NEBRASKA
Dept of Health & Human Svcs
Div of Publ Health, Lic Unit
Off of Nsg & Nsg Support
PO Box 94986
Lincoln, NE 68509-4986
402-471-0537
NEVADA
Bureau of Lic & Cert
1550 E College Pkwy, Ste 158
Carson City, NV 89706
775-687-4475
NEW HAMPSHIRE
NH Board of Nursing
21 S Fruit St, Ste 16
Concord, NH 03301-2431
603-271-8282
NEW JERSEY
Div of Health Facilities Evaluation
& Licensing NJ Dept of Health &
Senior Svcs
PO Box 367
Trenton, NJ 08625-0367
609-633-9171
NEW
MEXICO
DOH/DHI/Hlth Facility Lic & Cert
Bureau
2040 S Pacheco St
2
nd
Flr Rm 413
Santa Fe, NM 87505
505-476-9040
*NEW YORK
Bureau of Prof Credentialing
NY State Dept of Health
875 Central Ave
Albany, NY 12206
518-408-1297
*NORTH CAROLINA
Dept of Hlth & Human Svcs
Hlth Care Personnel Registry
Div of Facility Svcs
2709 Mail Service Ctr
Raleigh, NC 27699-2709
919-855-3969
NORTH DAKOTA
OBRA Mandated Registry
ND Dept of Health Facilities
600 E Blvd Ave, Dept 301
Bismarck, ND 58505-0200
701-328-2353
OHIO
Bureau of Info & Oper Support
OH Dept of Health
246 N High St
Columbus, OH 43215-2412
614-752-9500
OKLAHOMA
OK State Dept of Health
NA Registry
1000 NE 10
th
St, Rm 1111
OK City, OK 73117-1299
405-271-4085
OREGON
Cust Svc Ctr
OR State Board of Nursing
17938 SW Upper Boones Ferry Rd
Portland, OR 97224
971-673-0685
*PENNSYLVANIA
PA Nurse Aide Registry
Pearson Vue
PO Box 13785
Philadelphia, PA 19101-3785
800-852-0518
RHODE ISLAND
RI Dept of Hlth, Hlth Profes
3 Capitol Hill, Rm 105
Providence, RI 02908-5097
401-222-5888
*SOUTH CAROLINA
Pearson VUE
Corporate Hdqtrs
5601 Green Valley Dr
Bloomington, MN 55437-1099
952-681-3899
SOUTH DAKOTA
SD Board of Nursing
4305 S Louise, #201
Sioux Falls, SD 57106
605-362-2769
TENNESSEE
Div of Hlth Care Facilities
Dept of Health
227 French Landing, Ste 501
Heritage Pl, Metro Ctr
Nashville, TN 37243
615-532-7841
TEXAS
Dept of Aging & Disab Svcs
PO Box 149030, MC: E-414
Austin, TX 78714-9030
512-438-2050
UTAH
UT Hlth Tech Cert Center
550 East 300 South
Kaysville, UT 84037-2699
801-547-9947
VERMONT
VT State Board of Nursing
Natl Life Bldg, N Flr 2
Montpelier, VT 05620-3402
802-828-2819
VIRGIN ISLANDS
VI Board of Nurse Lic
PO Box 304247
Veterans Drive Station
St. Thomas, VI 00803
340-776-7131
VIRGINIA
VA Board of Nursing
NA Registry
9960 Mayland Dr, Ste 300
Richmond, VA 23233
804-367-4569
WASHINGTON
OBRA NA Registry
PO Box 45600
Olympia, WA 98504
360-725-2597
WEST VIRGINIA
Off of Hlth Fac Lic & Cert
1 Davis Sqr, Ste 101
Charleston, WV 25301-1799
304-558-0050
*WISCONSIN
WI NA Registry
PO Box 13785
Philadelphia, PA 19101-3785
877-329-8760
WYOMING
WY Board of Nursing
1810 Pioneer Ave
Cheyenne, WY 82002
307-777-7616
*These states do not fill out verification forms. If your verification is from one of the states with an *,
please complete Part I only and return the verification form to AZBN along with your application.
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PR OOF OF NURSE AIDE REGISTRATION PART I: (Arizona State Board of Nursing)

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Completed 20 July 2020

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